urology and renal Flashcards
what is the PIRADS score used for
used to rate the clinical significance of prostate cancer on MMRI (multi parametric MRI)
PIRADS 1- very low
PIRADS 2- low
PIRADS 3- intermediate/ equivocal
PIRADS 4- high
PIRADS 5- very high
carry out biopsy with MMRI Prostate result of PIRADS 3 and above
what is priapism, and what is the difference between ishcaemic and non ischaemic priapism
penis maintains a prolonged erection
ischaemic priapism
- rigid
- painful
- due to venous occlusion
non ischaemic priarism
- not fully rigid
- painless
- arterial flow isn’t working properly, often due to trauma
which cancer is aromatic amine exposure a risk factor for
bladder cancer
what dies transillumination a testicular swelling indicate
hydrocele
male
fever
chills
pain in perineal region
stinging sensation when passing urine
urinary frequency / hesitancy
cant tolerate rectal exam due to pain
likely diagnosis?
prostatitis
most common causative agent of prostatitis
E coli
sudden severe onset pain in left scrotum
no hx of trauma
left testicle is elevated and tender
absent cremasteric reflex
no pain relief on elevation of testicle
diagnosis
testicular torsion
what to do if suspect testicular torsion from examination and observation
immediate surgical exploration
if surgery cant redone, manual detorsion
(only do duplex ultrasound if it won’t delay the surgery), usually just do surgical exploration straight away
what does horizontal lie of testes indicate
bells clapper deformity
medication for prostatitis
oral ciprofloxacin 500mg twice daily
pt with prostate cancer presents with new onset leg weakness and incontinence
what investigation should be done and what are you looking for
MRI spine
to look for spinal cord compression due to metastases
what is balanitis
inflammation of the glans penis
what is phimosis
a congenital tightening of the opening of the foreskin so that it cannot be retracted
what is paraphimosis
inability to return a retracted foreskin over the glans, as opposed to inability to retract the foreskin over the glans
is a urological emergency because the prepuce becomes trapped behind the corona of the glans penis, causing vascular compromise to the glans
commonly occurs after cleaning or catheter insertion
what is lichen sclerosus
itchy white patches around the genitals or anus
increases chance of cancer
and can cause phimosis
some non cancer causes of raised PSA
BPH
UTI
older age
prostatitis
ejaculation
PTH
prostate injury
surgical procedures - insertion of catheter or surgical scope into the bladder
urinary retention
A 64-year-old man presents with urinary frequency, nocturia, and difficulty initiating urination. He denies dysuria, Haematuria, abdominal pain and lower back pain. His PSA result is elevated and a PR exam reveals a smooth, symmetrical prostate with a central sulcus
First line tx
alpha blocker eg tamsulosin
what is orchidopexy
surgery that moves the undescended testicle into the scrotum - corrects cryptorchidism
what is a varicocele and symptoms
a mass of varicose veins in the spermatic cord
dully achey feeling
testis feels like a ‘bag of worms’
does not transilluminate
not rlly painful
can be asymptomatic or present with a dragging sensation which disappears in the supine position.
where is epididymis felt
behind the testis
what effect can trazodone have on the penis
can cause priapism
what is interstitial cystitis
pain low down in your tummy, sudden urges to pee and needing to pee more often than normal.
The exact cause of interstitial cystitis is unknown. It’s not a bladder infection like other types of cystitis.
what are PDE5 inhibitors eg sildenafil taken for and what is an absolute C/I of taking them
treat erectile dysfunction (or pulmonary htn)
absolute contraindication: if the patient is taking organic nitrates. the two substances together can cause fatal hypotension
what medication can be given to pt with erectile dysfunction who takes isosorbide mononitrate
Intracavernosal prostaglandins
bluish appearance of scrotal skin
negative transillumination test
diagnosis
haematocele
Haematocele is a haemorrhage into the tunica vaginalis space, usually due to trauma, surgical injury or testis tumour
first line IX for suspected testicular cancer
ultrasound of scrotum
DONT BIOPSY TESTICULAR MASS as can seed cancer into rest of scrotum
woman leaks small volumes of urine when coughing, laughing, lifting
what is the most appropriate management
pelvic floor exercises
anterior painless swelling in his scrotum that has been gradually increasing in size over the past few months. The swelling transilluminates on examination.
diagnosis
hydrocele
if a pt is suffering from ischaemic priapism what is the first line management
aspiration
(to decompress the corpus cavernosa by aspiration and injection of a sympathomimetic to reduce the risk of tissue necrosis)
scrotal swelling that transilluminate in a baby under 1 years old
what is the course of action
observation
- Scrotal swelling which transilluminates suggest congenital communicating hydrocele, will usually resolve by 1 years
how to mange low risk localised prostate cancer in a pt with life expectancy of less than 10 years
active surveillance (the risks of treatment may outweigh the benefits)
advice for males before PSA test to avoid a false positive result
avoid ejaculation
(The serum PSA level rises immediately after ejaculation. If taken within 48 hours of ejaculation, it leads to a false positive result)
haematuria - and passing clothes in urine
urinary retention of 520 ml in bladder
PSA of 108
likely diagnosis
prostate cancer
which score is used for prostate cancer scoring
Gleason score
after catheter insertion
oedematous foreskin of glands with bluish discolouration
diagnosis?
paraphimosis
what is posthitis
inflammation of the foreskin caused by infection or irritation
presents with redness, swelling, and pain of the foreskin but does not cause difficulty in retracting the foreskin
what type of medication is sildenafil
PDE5 inhibitor
what is the most common symptom of metastatic prostatic cancer
lower back pain
signs of torsion of testicular appendage
a hard, tender nodule may be palpable on the upper pole of the testicle,
and a blue discoloration referred to as the “blue dot sign” may be visible in this area
3 main tumour marker sin testicular cancer
AFP
beta-hCG
LDH
How to manage unilateral undescended testis in a 4 month old
wait until 6 months of age - may descend by itself
if doesn’t descend by then refer to specialist who will perform orchidopexy
next step in management of BPH after pt is on tamsulosin, finasteride and is still symptomatic
TURP (transurethral resection of the prostate)
which Gleason score classifies a prostate cancer as low risk, so the tx is just active surveillance
6
which virus from the Paramyxoviridae family causes orchitis
mumps
what is nephrostomy
a procedure to drain urine from your kidney using a catheter
urgent management required for a pt with an obstructed left kidney (due to a stone) which has caused hydronephrosis? pt is febrile and urine is +ve for blood/leucocytes/nitrites
IV abx and surgical decompression or nephrostomy
(Extracorporeal shockwave lithotripsy (ESWL) should not be used for pts with active infection its only used for pts with uncomplicated stones)
what is hydronephrosis
kidneys swell due to build up of urine inside of them
cause of poor urinary stream/post micturition dribble in pt who had a radical prostatectomy
urethral stricture
how does prostatectomy affect PSA levels
PSA should fall, should remain low and stable
which electrolyte imbalance is present in TURP syndrome
hyponatraemia
what is the most common part of the prostate that BPH develops in
transitional zone
what is the most common part of the prostate that cancer develops in
peripheral zone
cause of bilateral hydronephrosis with no urinary symptoms other than incontinence in a 68 yr old man
BPH - causes bilateral obstruction, also is gradually growing not acute so causes the chronic retention the pt has (as they have no symptoms, acute presents with pain etc)
if you cannot ‘get on top’ of a swelling, what does this indicate
inguinal hernia
inability to delineate the superior margin is worrying for an inguinal hernia
main side effect of an orchietcomy
reduced fertility
what is the meatus of the penis
the opening where urine comes out
course of action for newborns with BILATERAL undescended testes
refer to a senior paediatrician for endocrine or genetic investigation (consider the possibility of an underlying pathology (commonly congenital adrenal hyperplasia (CAH))
what pathology can cause BILATERAL undescended testes in newborn
congenital adrenal hyperplasia
which medication is known to cause priapism
trazodone
what do bells clapper deformity and cryptorchidism increase the risk of
testicular torsion
first line tx for prostatitis
a quinolone eg ciprofloxacin
causes of bilateral hydronephrosis
Bilateral hydronephrosis = SUPER:
Stenosis of urethra,
Urethral valve,
Prostatic enlargement,
Extensive bladder tumour (i.e. obstructing both ureteral orifices),
Retroperitoneal fibrosis
symptoms of renal cancer
flank/loin mass
loin pain
flank pain
haematuria
what is the criteria for 2 ww referral for renal cancer
If they are aged 45 years and over and have:
Unexplained visible haematuria without urinary tract infection, or
Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
Tx of RCC vs TCC in renal cancer
transitional cell carcinoma
- chemo and surgery (partial/radical nephroureterectomy)
renal cell carcinoma
- surgery is the primary treatment (partial or radical nephrectomy)
nephroureterectomy vs nephrectomy
nephroureterectomy = removal of kidney, ureter and small piece of bladder where ureter and bladder connect
nephrectomy = removal of kidney
initial imaging fo a mass felt in flank which you suspect to be renal cancer
renal ultrasound
can do CT with IV contrast after
what does E coli look like under microscope
pink rod shaped bacteria
72 yr old with painless visible haematuria
next steps ?
2 ww referral to haemturia clinic - Visible haematuria is bladder cancer until proven otherwise
immediate management for acute urinary retention
insertion of urinary catheter
what is Robotically assisted laparoscopic prostatectomy used for
prostate cancer
what is Transurethral resection of the prostate used for
BPH
what lifestyle modifications can be taken to prevent recurrence of calcium oxalate stones
Reduce oral intake of rhubarb, spinach and tea (oxalate rich foods)
increasing dietary calcium intake.
what medication can be taken to prevent recurrence of calcium phosphate stones
thiazide like diuretics
3 substances in urine dipstick for UTI
leucocyte esterase and nitrites and blood
2 substances in urine dipstick for nephritic syndrome
protein and blood
pt with urine dipstick position for blood and renal US showing mild right sided hydronephrosis
alos lost 3kg in weight
likely diagnosis?
bladder cancer
(renal ultrasound would typically identify a mass)
what is the cause of haematuira after someone has been lying in the same position for a long time after a fall and has a raised CK
myoglobuniuria due to rhabdomyolysis
chronic fatigue, unilateral flank pain, secondary polycythaemia, microscopic haematuria and a left sided varicocele that fails to resolve on lying down
what is the like diagnosis
Renal cell carcinoma
what is the management if a patient is septic secondary to renal calculi
nephrostomy - the patient requires urgent decompression of the are septic
first line abx for a 10 week pregnant woman with UTI
nitrofuratonin
(Amoxicillin would be considered in this scenario as a second-line option if nitrofurantoin had been taken for at least 48 hours with no results, or when the first choice is not suitable due to possible organism resistance)
which type of kidney stones in penicillin given to prevent/reduce the number of, it also run-in the family
cystine kidney stones
Cystinuria is an autosomal recessively inherited metabolic disorder which predisposes to recurrent renal stones composed of cystine and urinary tract infections in childhood. Preventative treatment includes the prescription of penicillamine to reduce the amount of cystine present in the urine.
which medication can prevent struvite kidney stones
acetohydroxamic acid (AHA)
definitive management if clot retention occurs as a complication after TURP procedure
emergency clot evacuation and diathermy to the bleeding point
struvite kidney stones are associated with recurrent UTIs involving which bacteria?
Proteus bacteria
management of long pt with asymptotic microscopic haematuria
repeat urinalysis in a few weeks
first line and gold standard investigation for kidney stones
first line: urine dipstick
gold standard: non contrast CT KUB
tx for T2 / 7cm and above renal tumour without metastases
radical nephrectomy
(partial nephrectomy is used for T1 or <4cm tumours)
(immunotherapy eg biological are used for metastatic cancer or unresectable tumours)
what is a vaginal cystocele
wall between bladder and vagina weakness
causes the bladder to fall onto the vagina and compress it
main side effect of long term use of nitrofuratonin
pulmonary effects eg pulmonary fibrosis, ILD, interstitial pneumonia
what does urolithiasis means
kidney stones
what imaging modality is used to investigate painless visible haemturia
cystoscopy
balanopsthitis vs posthitis
balanopsthitis
= inflammation of penis and foreskin
posthitis
= inflammation of foreskin
what is functional incontinence
patient cant get to the toilet despite wanting to
- eg may be due to sedating medications
which recreational drug can cause cystitis
ketamine
if a pt has display myopia, dislocation of the lens, osteoporosis, learning difficulties and abnormal blood clotting
and gets acidic kidney stones with ground glass appearance, which runs in family
what are the stones likely to be made of
cystine
- pt is suffering with homocystinuria
(autosomal recessive)
which kidney stones run in family
cystine
which kidney stones can have a ground glass appearance
cystine
what is Haemorrhagic discolouration of the right flank called and what does it indicate
This describes Grey-Turner’s sign, which is indicative of bleeding into the peritoneum. (intraperitoneal or retroperitoneal hemorrhaging)
It is associated with acute pancreatitis ectopic pregnancy etc
what is Haemorrhagic discolouration of the umbilical area called and what does it indicate
This describes Cullen’s sign, which is indicative of bleeding into the peritoneum.
(intraperitoneal or retroperitoneal hemorrhaging)
It is associated with acute pancreatitis, ectopic pregnancy etc
what incontinence does episiotomy increase risk of
anal incontinence
what incontinence does multiparty increase risk of
stress incontinence
what is hydronephrosis and what tx is indicated for it
one or both kidneys stretch and swell due to ruin build up
insertion of urethral stent
what is used for pregnant women with kidney stones over 10 mm
ureteroscopy
extra corporeal shock wave lithiotripsy and
percutaneous nephrolithotomy are contraindicated in pregnancy
which incontinence can be triggered by sound of running water, tea and coffee, arriving/leaving home
urge incontinence (detrusor overactivity)
what is the cause if bilateral lower limbs oedema in someone with renal caner
inferior vena cava occlusion
Macroscopically: multifocal with flat to papillary lesions. Microscopically: foci of squamous differentiation or extensive keratinization and intercellular bridges
which renal cancer is this
transitional cell carcinoma
Macroscopically: Well circumscribed lesion, mostly golden with interspersed areas of hemorrhagic and fibrotic tissue. Microscopically: Well defined cell membranes with mostly transparent cytoplasm, interspersed with highly vascularised stroma
which renal cell cancer is this
clear cell renal cell carcinoma
how is balanoposthitis caused by lichen sclerosis in a young boy treated
circumcision
which type of cancer is a left sided varicocele suggestive of and why
renal cell carcinoma
the cancer compresses the left renal vein, causing blockage of left variceal veins –> varicocele
gold standard imaging modality for staging a renal cancer
CT abdomen/pelvis with IV contrast
what should be done if a kidney stone is blocking the kidney, causing hydronephrosis and infection in the kidney
urgent surgical decompression
is asymptomatic bacteriuria treated
no in men and non pregnant women
yes in pregnant women
which antibiotic should be used and which should be avoided in a breastfeeding woman
use trimethoprim, second line is amoxicillin
avoid nitrofuratonin
what is wills tumour
most common renal cancer in ages 2-5
what type of kidney stone causes stag horn calculi (ie the calculus/stone moulds to the shoe of the renal pelvis)
struvite
woman is constantly leaking urine. she has had a difficult and prolonged labour when having her last child
what is the diagnosis
vesicovaginal fistula
which malignancy is most likely to cause painless haematuria in an older male with a significant smoking history
TCC ofd the bladder
what causes abdominal mass with flank pain
renal cancer
which bladder cancer is most common in people who have chronic inflammation of the bladder (e.g. long term catheter or history of schistosomiasis)
squamous cell carcinoma of bladder
criteria for 2 ww referral for haematuria
If they are aged 45 years and over and have:
1) Unexplained visible haematuria without urinary tract infection
or 2) Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
first line scans for visible haemturia
ct urogram and cystoscopy
tx for fungal balanoposthitis
counselling on genital hygiene and topical antifungal agents (eg. Co-trimazole)
A 52 year old woman presents with recurrent left sided loin pain and fevers. She suffers from recurrent pyelonephritis. A CT scan of the Kidneys, Ureters and Bladders (CT KUB) shows a staghorn calculus
which infective organism is the most likely cause
proteus bacteria
what antibiotic class is ciprofloxacin
quinolone - used to treat pyelonephritis in hospital
what are vesicovaginal fistulas caused by
prolonged and obstructed vaginal childbirths
what type of incontinence can lots of opiates and sedatives cause
functional incontinence
most common type of renal stone
calcium oxalate
what does terminal (ie at the end of voiding), painful haematuria indicate
bladder calculi
what is neurogenic bladder
lack of control of bladder due to brain/nerve/spine issue
occurs in conditions such as MS, stroke, diabetes, Parkinson’s
bladder hyperactivity, bladder spasms, urinary urgency and frequency
which antibiotic can be used for UTI in pt with G6PD deficiency
cefalexin
(trimethoprim and nitrofuratonin are contraindicated)
why should a pt be kept in hospital after catheterisation of their acute urinary retention
to monitor for if they develop post obstructive diuresis
prolonged polyuria, excessive salt and water los –> dehydration
develops after rapid decompression of urinary retention
can cause AKI
is a major concern for pts with mention volumes > 1000ml
what is the tx for pts with renal cancer of T2 and above
radical nephrectomy
what is the likely cause of a week of difficulty passing urine and 3 days of vision loss
has had a similar episode before
MS
what is a pessary ring used for
vaginal prolapse
what is the tx for localised renal cell carcinoma of 3.5 cm
partial nephrectomy (Partial nephrectomy is the preferred treatment for localised renal cell carcinoma less than 4 cm in size)
haemturia, flank pain, mass
diagnosis
renal cell carcinoma
which hyperparathyroidism is a common complication of CKD
Secondary hyperparathyroidism
ACEi and ARB in pts with CKD and hypertension should be stopped if the serum potassium concentration exceeds what number
6
which investigation allows you to visualise the flow through the urinary system and is most useful when an obstruction is suspected
IV urogram
sessile vs papillary tumours
Flat tumors (Sessile) are flat, superficial, spreading tumors. These tumors are often more difficult to treat. Papillary tumors have long, finger-like projections that stretch out from the bladder wall toward your bladder’s interior.
contrast autosomal dominant and autosomal recessive polycystic kidney disease
autosomal dominant
caused by a mutation on chromosome 16
presents in adults
autosomal recessive
caused by a mutation on chromosome 9
presents in infants
adult pt has a subarachnoid haemorrhage and has bilateral flank masses which do not move on respiration
diagnosis?
autosomal dominant polycystic kidney disease
(autosomal dominant in adults, autosomal recessive in children)
what does periorbital oedema in a young child with no history of allergen exposure suggest
nephrotic syndrome
what syndrome does ‘cant see, cant pee can’t hear a bee’ refer to
Alport’s sydnrome
- retinal flecks
- haematuria
- bilateral sensineural hearing loss
which investigation provides a definitive diagnosis of nephrotic syndrome
renal biopsy
first investigation when a patient presents with postoperative urinary retention
bladder scan or ultrasound
what findings in urine indicate rhabdomyolysis
decreased urea:creatinine ratio
elevated CK
likely cause of high urea in body builder’s urine
protein supplement use
pt presents with significant periorbital oedema, frothy urine and swollen red painful leg
what is the likely cause of the painful leg
DVT
(nephrotic syndrome can cause hypercoagualibity)
what type of anaemia does CKD cause
normocytic normochromic anaemia
This is because the kidneys are responsible for the production of erythropoietin which promotes erythropoiesis in the bone marrow
what is the biggest risk factor for bladder cancer
smoking
how is creatinine clearance for each pt calculated and which variables are taken into account
using the Cockcroft-Gault formula,
which requires the following variables:
age,
gender,
creatinine
weight
what is another word for Berger’s disease
IgA nephropathy
what do kidneys in CKD look like on US
Bilaterally shrunken
Enlarged left kidney on ultrasound and raised serum urea and creatinine
what does this suggest
hydronephrosis
how are bicarbonate levels affected on renal impairment
reduced
This is because the kidneys excrete hydrogen ions, which accumulate in renal impairment and reduce serum bicarbonate levels
what is the most common viral cause of focal segmental glomerulosclerosis
HIV
what type of acidosis can CKD cause
CKD can cause met acidosis due to decreased production of sodium bicarbonate
how to correct/treat normocytic nomochromic anaemia in CKD pt
give EPO
BUT if there is iron deficiency, correct this first, as giving EPO can exacerbate it
AA amyloid vs AL amyloid
AA amyloid (associated with inflammation) rather than AL amyloid (associated with autoimmune conditions)
pt presents with a local muscle invasive tumour contained within the bladder. Further investigations show no evidence of metastases
management?
cystectomy
(not TURBT, that is for grade T1 or superficial tumours)
what is the likely cause of acute onset new abdo pain, haematuria and oedema in a pt with nephrotic syndrome
renal vein thrombosis
what is the most reliable indicator of rhabdomyolysis
raised CK
muscles aches and pains and red-brown urine
diagnosis?
rhabdomyolysis
which diabetic med should be stopped in AKI if eGFR is < 30
metformin
how can you judge if a pts AKI will progress to CKD/ESRF or full recovery
if
pts baseline urea and creatinine indicate normal renal function before the KI
repeat U&Es after starting Tx indicate recovery
and pt asks pre existing risk factors
you expect full recovery
what are the common drugs that need to be stopped in AKI
“Stop the DAMN drugs”:
Diuretics and digoxin
ACE inhibitor/ ARB
Metformin and methotrexate
NSAIDs
